=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003000522
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | FREDERICK J WEIGAND MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/28/2007
-----------------------------------------------------
Last Update Date | 01/04/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1565 SAXON BLVD SUITE 102
-----------------------------------------------------
City | DELTONA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32725-5876
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-917-7395
-----------------------------------------------------
Fax | 386-532-7152
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1565 SAXON BLVD STE 102
-----------------------------------------------------
City | DELTONA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32725-5823
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-917-7395
-----------------------------------------------------
Fax | 386-532-7152
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QA0505X
-----------------------------------------------------
Taxonomy Name | Adult Medicine Physician
-----------------------------------------------------
License Number | ME13473
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------